Perspective by renowned nephrologist Dr. Brad Rovin

Recognized as National Kidney Month, March is the ideal time to learn more about the 2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis. Recently issued, the guidelines are designed to provide healthcare providers with up-to-date guidance on the care and treatment of adults and children with lupus nephritis – the most common and severe manifestation of systemic lupus erythematosus (SLE).

The new guidance represents the recent shift in lupus nephritis treatment that involves moving away from separate initial and maintenance therapy phases to a continuous combination or “triple therapy approach.” This new strategy targets multiple parts of the immune system at the same time, providing a more comprehensive and sustained treatment approach.

The primary goal is to safeguard kidney function and reduce the long-term health impacts and mortality rates associated with chronic kidney disease, while minimizing the side effects of the medications used. Read article for summary of guidelines.

To put the new guidelines in perspective for our lupus community, we interviewed Dr. Brad Rovin, one of the key architects of the new guidelines and member of the Lupus Clinical Investigators Network (LuCIN) overseen by Lupus Therapeutics, the clinical research affiliate of the LRA.

Q:  What are the key recommendations of the new lupus nephritis guidelines that you feel will make the greatest impact on treatment?
A: The most significant recommendation, and the recommendation that differentiates this guideline from all other current lupus nephritis guidelines, is that patients be considered for triple therapy right from the time of diagnosis. Triple therapy incorporates a background therapy with steroids and the immunosuppressant mycophenolate (which most patients with LN are currently taking), plus the addition of one of the more recently approved drugs for lupus nephritis — either voclosporin or belimumab.

This recommendation is based on clinical trials that showed more patients were able to achieve a complete kidney response with triple therapy than with steroids and mycophenolate alone. But beyond kidney responses, the triple therapies provide additional benefits to the kidneys by reducing lupus nephritis flare rates, preserving kidney function, and preserving the structure of the filtering units of the kidneys glomeruli.

In addition, the guidelines advocate for lower overall steroid use, if possible, as well as the frequent monitoring of kidney function and urine protein to try and catch disease activity early.

These recommendations and suggestions aim to help control the immune disease that causes lupus/lupus nephritis and keep the kidneys healthy and working for as long as possible.

Q: What issues were these guidelines designed to address?
A: The guidelines are designed to help healthcare providers evaluate and monitor patients, understand all the therapies available for use and their benefits and downsides, and to provide a framework for how a provider may manage each individual patient. Of critical importance to both patients and providers, the guidelines are based on the best available scientific evidence, and in the absence of high-level evidence, on consensus from lupus physicians with years of experience. The other important point to keep in mind is that these guidelines serve as a living document that will continue to be updated frequently as new evidence becomes available and as other novel therapies are approved for use.

Q: As a nephrologist seeing many patients with lupus nephritis, how may these new guidelines change your treatment?
Although I was involved in the trials that led to the approval of both new drugs for lupus nephritis, belimumab and voclosporin, I often used dual therapy first (steroid and mycophenolate).  But based upon the available clinical data, the new medications, and my patients, I had already changed my approach to triple therapy. This helped me advocate for this in the current guidelines, as I had the privilege of being a member of the core group of lupus providers tasked with developing these guidelines.

Q: Do you find that insurance companies are covering the use of triple therapy? Do you expect that these guidelines will influence coverage?
A: Unlike when voclosporin and belimumab were first FDA-approved, I am not having much resistance from insurance companies for covering triple therapy.

Q: How would you recommend patients learn more about these guidelines?
A: I think that organizations like the Lupus Research Alliance and the Lupus Foundation of America, in partnership with the many individuals who developed the guidelines should and indeed are providing educational information about the guidelines especially for patients. It’s important to point out that patients were involved in the guideline development meetings and could also be a valuable source of information for other individuals with lupus.

Q: Would you recommend that patients also ask their healthcare provider about how these new guidelines may influence their treatment?
A: The easy answer is yes, of course do that. But because not all healthcare providers may be fully acquainted with the new guidelines, patients can also benefit from the sort of the education that articles like this offer along with future resources to be provided by lupus organizations such as the Lupus Research Alliance and Lupus Therapeutics for both patients and providers.